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Prevost, Alexander f ��3 Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: M8 ei,,pAtz RETURN TIME: DATE & TIME REMAINS ARRIVED AT CREMATORY: 12 fr) I 1Z /0.00141 NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: Ittiog r Li,p4 te_ NAME: ZiA14DU, `Qt`uoSCr' CASE # q TYPE OF CONTAINER: 4t<bt�eq,� Ake" 76. ,.i I7JboaS PLACE OF DEATH: S� l told S} ���� �1J I J Il O ESTIMATED WEIGHT OF REMAINS & CONTAINER (3-0 livr sralee/ PLACED IN HOLD: r0;/i411 PLACED IN REFRIGERATION: DATE OF CREMATION: I'Il l ZZ TIME STARTED: an TIME COMPLETED: 3.00tr) PLACED IN RETORT: I ,I Qf MOVED: ZJ Th Z-kt o T h RETORT# IN WHICH REMAINS WERE CREMATED: 17vw PA ell_ DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY. u - New York State Department of State 7_1—NEW YORK DIVISION OF CEMETERIES STATE OF Division of One Commerce Plaza OPPORTUNITY.. Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)474-6226 www.dos.ny.gov Authorization for Cremation and Disposition This Authorization Form must be completed and signed prior to delivery of remains for cremation. December 6, 2022 q sg Date: Number: Crematory Name: Pine View Crematory Address:21 Quaker Road, Queensbury, NY 12804 Phone: 518-745-4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal, which are all that will be left after cremation. Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation chamber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no single fragment is recognizable as skeletal tissue. OPENING OF THE CONTAINER The crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect. IDENTIFICATION OF DECEASED Name of Deceased: Alexander Prevost Never Married Marital Status: Last Known Address: 56 Leonard St Glens Falls New York 12801 Place of Death: 56 Leonard St. Glens Falls, New York 12801 Sex: © M ❑ F Age: 32 DOB: 11/30/1990 Date of Death: 12-05-2022 Estimated Weight: 150 Description of casket/container in which remains will be delivered. Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial ONE of the following) I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law Section 4201. -OR- If I/W ha e no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a wning directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: Alexander Prevost (Name of Deceased) DOS-1898-f(Rev. 04/20) Page 1 of 3 .7 Authorization for Cremation and Disposition �� (Initial the following) V I/We understand that if the remains are not claimed within 120 days of cremation, Pin View Crematory may dispose of the remains in (Name of Crematory) an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the following) An urn to be used as a container for the cremated remains has been purchased from M B Kilmer Funeral Home and is described as follows: . I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery. -OR- rAn urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pine iew Crematory will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. Claire C. Konopka This Authorization Form was provided by was executed at (Funeral Director Name) M.B. Kilmer Funeral Home (Funeral Home Name) 136 Man St. South Glens Falls New York (Funeral Home Address) and is signed by the funeral director as witness to its execution. I/We have received a completed copy of this Authorization Form. The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s) to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing. Signed this 6 day of December ,20 22 _ Mark Prevost Typed or Printed Name Sig 56 Leonard St. Glens Falls, NY 12803 e/ =. Address t Kim Maslack 4-1.� ,/� ) T onName Signature r 430 11 V /rQN` ik. t�'1 �ti Typed or�ted Name V 6 ` Signature Address WITNESS: Claire C. Konopka C--e w. Krv"---.-Y tom_ (Funeral Director Typed or Printed Name) (Funeral Director Signature) 11932 (Registration Number) Alexander Prevost (Name of Deceased) DOS-1898-f(Rev. 04/20) Page 3 of 3 Pine View Cemetery and Crematorium 21 Quaker Road Queensbury, NY 12804 Authorization to Separate Cremated Remains Funeral Home M B Kilmer Funeral Home Director Claire C. Konopka Date December 6, 2022 Tag No. I/we authorize the separation of the cremated remains of Alexander G. Prevost I/we further agree to hold harmless,indemnify and defend the herein named crematorium as well as their representatives,from and against all claims,liabilities or damages whatsoever which may result from this authorization. Signature L � � Crematory Operator March 2015